Selina Rajan MBBS MSc and Martin Mckee DSc (The London School of Hygiene and Tropical Medicine – Department of Health Services Research and Policy).
The full report is available here:
Care home residents in England now account for over 40% of known COVID-19 deaths in England. Care homes are people’s homes and are not intended to replicate the clinical environments in a hospital, so that transmission of COVID-19 between some of the frailest members of society are especially difficult to prevent. In this paper, we report how the lived experiences of care home providers can provide important insights that inform a whole system response that will be required to prevent future avoidable fatalities in care homes in the event of a second wave of infections.
We conducted an anonymous online pilot survey of care home managers and directors across England, surveyed between May 15th and June 1st. We ask what challenges care homes faced during the COVID-19 pandemic, what strategies they used to mitigate them and what they would need in future to strengthen their response. The survey covered four key themes, including infection control, workforce, wellbeing of residents and partnership working. We received responses from 35 care home directors and 42 care home managers, of whom 34% had reported an outbreak of COVID-19; a similar proportion to the national average at the time.
Partnership working: The level of support obtained from local authorities and Clinical Commissioning Groups (CCGs) varied dramatically across the country and many providers had still received no financial support at the time of the survey. Some, but not all local authorities hosted daily calls with care homes and a handful provided PPE and financial support, but this was limited. Some felt that decision-makers in local authorities and CCGs were detached from the realities in social care, preventing opportunities for truly collaborative working.
The ask: Respondents called for more accessible financial support, partnership working, and a supportive culture including the ability to co-design formal guidance and having sufficient warning to implement it, as well as support when facing staffing shortages and psychological support for their workers.
Infection control: Care home managers and directors reported that they rarely were unable to provide the PPE they required but faced immense challenges dealing with a chaotic supply chain and dramatically inflated costs. 30% also reported that it was not always possible to isolate residents, while 45% were at times unable to isolate residents who walked with purpose. Many described frustration with frequently changing guidance, with that from different sources often conflicting and impossible to implement. Tests for residents and staff were often inaccessible, processes poorly coordinated, and results delayed. At the time of the survey only 40% of care homes had been able to access testing for asymptomatic residents.
The ask: Care homes called for a well-resourced supply chain of PPE; joined up, timely, and coherent guidance that is feasible to implement in long-term care settings, access to regular and efficient testing for all staff and residents and accurate clinical information on hospital discharges.
Workforce: More than 70% of care home managers reported that they had concerns about staff morale and their mental health and wellbeing. They described a fearful and overworked workforce who felt the pressure of responsibility to protect residents from becoming infected at all costs. Many managers and directors described their frustration at the lack of parity between the NHS and social care and their struggles to maintain morale. 43% of managers also described staff shortages and 30% of care homes still depended on staff who worked across sites, with some reluctantly having to use agency staff at inflated prices to fill gaps. Peer to peer support, activities, community donations and letters of appreciation were the mainstay of support for staff and some providers also supported their staff with bonuses and enhanced pay.
The ask: Care homes called for better team working between the NHS and social care, support with recruitment and , volunteers and, again, better access to testing.
Wellbeing of residents: Managers reported that isolation had impacted residents’ mood in over 80% of homes, and almost all believed that the absence of visitors was a key factor, as well as the barriers created by PPE to maintaining relationships. Reduced oral intake was also reported in one third of care homes and this was most often attributed to isolation. Homes had used imaginative measures to keep residents informed, stimulated, and mobile despite social distancing policies and sought to facilitate virtual contact with relatives where possible.